According to the
American Migraine Study II (Lipton, Diamond, Reed, Diamond & Stewart,
2001), approximately 28 million Americans are affected by migraines. In 1989,
approximately 38% of survey participants were diagnosed with migraines,
compared with 48% in 1999. Since migraines are a major cause of absenteeism
from work (costing employers $13 billion per year! [Lipton et al., 2001]) and
can significantly disrupt normal family-life, this increase is troubling. In
their study, Lipton et al. mailed 20000 self-report headache questionnaires to
a representative sampling of households. Using the International Headache
Society criteria, researchers then diagnosed and classified respondents based on
whether or not they suffered from migraines.

Results showed
that only about half of the survey participants who met criteria for migraines
had been previously diagnosed as such. Thus, it appears that many Americans
are suffering through a debilitating condition without a proper diagnosis. For
those who are properly diagnosed, there are many treatment options available.
One treatment option, which has become increasingly popular over the past
decades, is the use of biofeedback to prevent and treat migraines. A general
search of the world-wide web reveals that biofeedback is effective in
decreasing the severity, duration, and frequency of migraines, with only one
web site contradicting this claim (http://www.migraines.org/treatment/treatalt.htm).
Furthermore, the scientific, rigorous studies of these claims substantiate the
efficacy of biofeedback on migraine intensity, confirming the claims of the
general websites.

What is a Migraine? (symptoms and theories of causation)

The intense pain
of a migraine can last anywhere from a few hours to several days (National
Headache Foundation [NHF]: “Migraine Headaches and Treatment” http://www.headaches.org/consumer/educationmoduleindex.html#
). Migraine symptoms include: intense, pulsating pain, nausea, dizziness,
vomiting, sensitivity to light, sensitivity to sound, experiencing blind spots,
and seeing flashing lights or lines (NHF). Symptoms can come on suddenly or
can be preceded by an aura. An aura basically refers to the sensory or visual
distortions that can accompany migraines, such as blind spots or flashing
lights. An aura serves to warn of an impending migraine, and disappears with
initial pain of the migraine itself (NHF).

*Migraines
lead to absenteeism from work and disruptions in family-life*

There are two main
theories which explain the cause of migraine pain. The more prevalent theory
is the vascular or blood flow explanation. According to Webster (2001;
accessed at: http://www.desertskypress.com/files/migraine1.pdf
), arteries within the head constrict (vasoconstriction), decreasing blood flow
to some brain cells, which therefore affects sight and motor sensations. At
the end of vasoconstriction the arteries dilate (vasodilation), creating a
situation wherein the vessels press on the adjacent nerves, causing the intense
pain of the migraine (NHF: “Migraine Headaches and Treatment”).

A second,
neurological theory, suggests that migraines are caused by changes in chemicals
in the brain which engender changes in the vascular system (NHF: “Migraine
Headaches and Treatment”). Specifically, serotonin is an important
neurotransmitter which appears to regulate messages regarding the contractions
and dilations of the blood vessels, and is therefore thought to be important in
migraines (NHF: “Migraine Headaches and Treatment). Interestingly, positron
emission tomography (PET) scans have shown both changes in chemicals and blood
vessels in the brain. As a result, there are still many unanswered questions
regarding the causes of migraines. However, according to the National Headache
Foundation (“Migraine Headaches and Treatment”), 80% of migraine sufferers have
a family history of migraines, and women are three times more likely to suffer
from migraines than men. This data implies that a genetic component or a
predisposition for migraines may exist, and more research needs to be done to
determine the concrete cause(s) of this condition.

What is Biofeedback?

There are
automatic functions in our body that occur outside of our conscious awareness.
For instance, an individual does not think about the process of breathing or
having to breathe in and out every few seconds, they just naturally do so. In
a similar fashion, other functions such as heart rate and skin temperature work
on an automatic basis. “Simply put, biofeedback is a means for gaining control
of your body processes to increase relaxation, relieve pain, and develop
healthier, more comfortable life patterns” (http://www.bio-medical.com/homeuse-home.cfm).
Essentially, biofeedback equipment allows an individual to monitor their body’s
automatic activities, particularly their reactivity to stress. The idea behind
biofeedback is that once an individual learns how to monitor their body’s
reactions, they can learn how to alter them. For example, the individual can
consciously learn how to monitor and change their heart rate and skin
temperature.

*Monitoring your temperature with a thermometer is a
simple form of biofeedback*

For individuals
with migraines, biofeedback relates back to the vascular theory of the causes
of migraines. The rationale behind biofeedback as a treatment for migraines is
embedded in the vascular theory; that migraines are a result of the processes
of vasoconstriction and vasodilation mentioned earlier. This theory further
suggests that the blood flow during migraines has been increased to certain
areas in the head and decreased to the extremities. Therefore, if a migraine
sufferer can modify the temperature of another body part (e.g. their hands)
through biofeedback, then the blood flow will automatically increase to the
extremities and decrease to the “strained” vessels in the head. When the vasodilation/swelling
of the blood vessels begins to diminish, the throbbing, pulsating, head pain
disappears (http://www.holistic-online.com/Remedies/migraine/mig_biofeedback.htm;
Webster, 2001) and the treatment has proven effective.

Types of Biofeedback

There are many
different types of biofeedback. EMG biofeedback provides information regarding
muscle tension, whereas thermal biofeedback (referred to as temperature biofeedback
and handwarming biofeedback, interchangeably) and blood flow biofeedback both
provide information regarding blood flow. The latter two methods of
biofeedback are suggested treatments for migraine sufferers. Essentially,
regardless of the type of biofeedback implemented, training in this treatment
begins with the equipment. An individual is hooked up to sensors, which depict
their body’s physiology on a computer screen. This then allows the individual
to monitor their automatic processes on the screen. Eventually, the individual
will be able to recognize/become aware of their body’s reactions without the
equipment.

Temperature biofeedback
assumes that the colder the temperature of the skin, the less blood that is
flowing to this area. For this form of biofeedback, a temperature wire is
attached to one of the individual’s fingers. In contrast, the ability to
measure blood flow directly requires the use of a photoplethysmograph.
However, according to Webster (2001), temperature biofeedback and use of a
photoplethysmograph have produced identical results. This suggests that
temperature biofeedback, which is much less expensive, may be the most
practical means of learning biofeedback. For this form of biofeedback, the
patient concentrates on warming their hands, in an attempt to increase blood
flow to this area. Webster suggests that by practicing this form of
biofeedback, the vascular system can actually be retrained, potentially
preventing future migraines.

According to
Webster (2001), a migraine sufferer who practices this form of biofeedback for
20-30 minutes 2 to 3 times a week, will learn the skills necessary to decrease
the severity of a migraine attack and even prevent an attack (if the technique
is employed during the “aura” phase).

Is biofeedback an effective treatment for migraines?

The current
scientific literature regarding the use of biofeedback to treat migraines is
remarkably consistent with the popular claims on the world-wide web (e.g., the
National Headache Foundation website: http://www.headaches.org/).
Many controlled studies have been conducted to assess the efficacy of
biofeedback on both adults and children with migraines. Results from these
studies suggest that biofeedback, especially temperature biofeedback, is
effective in treating episodes of migraine pain, as well as preventing future
episodes from occurring.

For instance, in a
pilot study (Powers, Mitchell, Byars, Bentti, LeCates, et al., 2001), 20
children who had been clinically diagnosed with migraines underwent a one-hour
session of what was termed “biofeedback-assisted relaxation training (BART)”.
During this time, children were taught relaxation techniques while there
“peripheral body temperature” (PBT) was recorded. The results of the study
showed that children were able to raise their PBT after BART, and that headache
severity, frequency, and duration decreased. “In general, 85% of parents
reported that their child was functioning “better” at T2 [after BART] as
compared with T1 [before BART]” (Powers, et al.). A brief summary of this
study and its results, originally published in Neurology, can be found
at: http://www.findarticles.com/p/articles/mi_m0BJI/is_4_31/ai_71900903.

Another study
examined the efficacy of biofeedback in three case studies, two of which
involved migraine sufferers (Earles, Folen, & James, 2001). A unique
component to this study was that patients and physicians communicated via
videophone during their biofeedback training sessions. Results indicated that
drastic improvements occurred in all three cases treated with biofeedback.
Specifically, the two migraine sufferers both reported at least a 50% reduction
in the severity and number of migraines experienced after treatment (Earles, et
al.). However, results of this study should be interpreted cautiously; case
studies are not done in controlled environments, they are not always
replicable, and they are hard to generalize to society as a whole. This study
therefore needs replication with a prospective design and a greater number of
case studies in order to create more interpretable results.

Furthermore,
Sharff, Marcus, and Masek (2002) conducted a study to examine the effects of
handwarming biofeedback, as compared to handcooling biofeedback and no
treatment at all. In their study, Sharff et al. randomly assigned 36 children
into one of the three treatment groups. The handwarming group then received four
one-hour sessions within a 6 week time-frame, which included cognitive
behavioral stress management training and 30 minutes of handwarming biofeedback
training. The handcooling group also received four one-hour sessions within a
6 week time-frame, which included 30 minutes of handcooling biofeedback
training. The control group was exposed to neither treatment. Sharff et al.
found that the children who were in the handwarming biofeedback group improved
more than the comparison groups, and sustained this improvement for up to 6
months later. However, a potential confound in the results of this study exist
due to the fact that the children in the handwarming biofeedback group also
received stress management training, whereas the handcooling biofeedback group
did not. Replication of this study without this added advantage is needed to
confirm that their results were indeed due to the handwarming biofeedback, and
not the stress management training or the combination of the two.

Beyond examining the effect
of biofeedback alone, results from a study conducted by Grazzi, Andrasik,
D’Amico, Leone, Usai, et al. (2002) suggest that the use of biofeedback in
combination with medication is more successful than medication alone in
treating migraines. In their study, they examined 61 participants who were
classified as having “transformed migraines,” meaning a previous history of
migraines which led to chronic daily headaches. These participants were
quasi-randomized (people who lived farther away were not forced to participate
in the biofeedback training and could be in the medication only group) into a
combined medication/biofeedback group and a medication only group. Results
showed a relapse rate of 42.1% (16 of 38) for participants in the medication
only group vs. a relapse rate of only 12.5% (2 of 16) for the medication plus
biofeedback group at year 3 of follow-up. This study therefore suggests that a
combination of medication and biofeedback rather than either by itself may
perhaps be the best means of treating migraines, specifically transformed
migraines. However, a fundamental flaw in the methodology of this study lies
in the fact that they did not have a biofeedback only group. Future studies
need to examine how effective biofeedback is alone when compared with
biofeedback plus medication, and medication only in the treatment of
migraines.

Finally, Vasudeva, Claggett,
Tietjen, and McGrady (2002) conducted a study to examine whether migraine
sufferers who experienced aura reacted differently to biofeedback/relaxation
than those without, and if this was accounted for by blood flow velocity. In
this study, forty participants were randomly assigned to either the biofeedback
treatment group or the control group. The biofeedback group then underwent 12
fifty-minute sessions of biofeedback assisted relaxation therapy. The
researchers included both EMG biofeedback and thermal biofeedback over the
course of the sessions. The results show that post-treatment, the biofeedback
group experienced a decline in the severity of their migraine pain and also
reported using less migraine medication to treat/control the pain.
Additionally, migraine sufferers with aura reacted similarly to migraine
sufferers without aura; no significant differences were found in how the two
groups responded to biofeedback. Furthermore, no association between
biofeedback-assisted relaxation and blood flow velocity was found. Therefore,
this study provides corroborating evidence for the notion that biofeedback is
an effective treatment for migraines.

Conclusion

In conclusion, both
general information websites and scientific literature support the use of
biofeedback as an effective treatment for migraine headaches. While this
technique may be more time-consuming (at least initially) for the migraine
sufferer than simply taking analgesic medication, the long-term preventative
benefits in terms of decreased severity, frequency, and duration suggest that
this treatment is worth the time and effort it takes to master the techniques
involved.